Health Care Debate: A Done Deal

Though the difficult battle still lies ahead, President Clinton has already won the health care war. Now it's up to him to negotiate the terms of his victory.

Clinton has done what Presidents Franklin Roosevelt, Harry Truman and Richard Nixon before him could not: he has made universal health care coverage inevitable.

Despite some ambivalence about the specific plan Clinton has presented, no one denies that somehow, within a few years, all Americans will be guaranteed access to affordable health care. Former Nixon aide William Safire calls the passage of "universal and irrevocable" health insurance a given. Senator Daniel Patrick Moynihan, another frustrated veteran of Nixon's failed efforts, insists that Congress will pass health care reform legislation next year. Even the conservative Heritage Foundation admits the government should ensure universal coverage, going so far as to promote the government program that pays two-thirds of the cost of care for federal employees.

Not even Bob Dole and his Grandstanding Obstructionist Party will deny that, 58 years after FDR dropped national health insurance from the Social Security Act for fear of sinking the entire bill, the time has come to guarantee health care for all Americans. The various proposals that Republicans have presented differ from the Clinton plan only in structure, not in goals.

Of course, President Clinton does not deserve full credit for this nearly unanimous attitude of inevitability. The public call for reform long preceded Clinton's speech last Wednesday, or even his election last November. Pennsylvania Senator Harris Wofford reacted to the desire for universal health care long before Clinton did. And the person whose presidential campaign focused most on health care was Bob Kerrey, not Bill Clinton.

But none of these events made reform inevitable--it took Clinton to do that. It is unlikely that George Bush, had he been re-elected, would have capitalized on the political momentum for health care reform. Clinton, on the other hand, has not only capitalized on this momentum; he has cultivated it, nurtured it--and staked his presidency on it. More than National Service, more than don't-ask-don't-tell, more even than his budget, the issue of health care will define Clinton's presidency and determine his chances for re-election. He guaranteed this by entrusting his wife (and her reputation) with the task of designing and selling the reform.

The Clinton plan isn't perfect. For one thing, it is an immensely complicated way to achieve the simplicity the president promises.

It will establish a new bureaucracy with broad regulatory powers--hardly a recipe for eliminating waste or reinventing government. The plan probably puts too much faith in the ability of government to determine adequate health benefits, ensure quality, promote competition and keep costs low.

The Clinton approach to that last part--keeping costs low--is particularly troubling, since the president's proposal for price ceilings is essentially a promise of price controls that blatantly contradict the goal of promoting competition and quality.

Finally, although the desire to shift the emphasis from specialization to primary care is an admirable (and essential) one, the suggestion that the government will decide how many people can study a given medical field is a bit too intrusive.

These faults notwithstanding, the Clinton plan is clearly a legitimate framework for debate. If the president is willing to compromise on the specifics without capitulating on the goals, the result will undoubtedly be an incalculable improvement on the present system. Clinton should realize that although the nation wants, and desperately needs, health care reform, that doesn't mean Americans feel passionately about managed competition.

As long as the goal of universal access to affordable health care remain unchanged, Clinton will have won a tremendous victory for himself politically and for the nation. But within the guidelines of that goal, the president should be flexible about the specific details of his plan.

Of course, flexibility doesn't mean Clinton should allow a swarm of interest groups to erode the plan until it's little more than a glorified expansion of Medicare. When that happened with his budget, Clinton looked weak, not flexible.

Americans want their president to stand for something and be willing to fight for it--qualities Clinton has not yet demonstrated adequately (witness Lani Guinier, Bosnia, Haiti and the unsatisfactorily-resolved issue of gays in the military). But it will suffice if Clinton stands for health security and affordability; he need not stand for anything as specific as health alliances, insurance pools or price ceilings.

Having established a framework for debate and ensured that the end result will probably be some variation on the theme of managed competition, the president needs to guide the national dialogue without manipulating it. As someone who clearly relishes the role of America's only elected talk show host, he should promote a meaningful national discussion about the merits of his proposal and possible improvements on it.

Instead of cynically exaggerating the benefits and savings of his plan, Clinton should present the plan's advantages honestly to demonstrate his sincere belief that it's a good plan.

He should also frankly concede that there are some weaknesses in his plan, and he should welcome all well-meaning suggestions to improve it--even those that come from Republicans.

Hammering out the specifics of health care reform will unquestionably be a contentious and complicated process. But the fact that the process is inevitable is a tribute to the political skills, the persuasiveness and the commitment of President Clinton.